Methods for measuring carcinoembryonic antigen

ABSTRACT

Disclosed herein are methods of accurately measuring carcinoembryonic antigen in a biological sample and methods of identifying and treating a mucinous cyst in a subject.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application claims the benefit of U.S. Provisional Application No. 61/731,725 entitled “Methods for measuring carcinoembryonic antigen” filed Nov. 30, 2012, U.S. Provisional Application No. 61/824,623 entitled “Methods for measuring carcinoembryonic antigen” filed May 17, 2013, and U.S. Provisional Application No. 61/840,963 entitled “Methods for measuring carcinoembryonic antigen” filed Jun. 28, 2013, each of which are hereby incorporated herein by reference in their entirety.

GOVERNMENT INTERESTS

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PARTIES TO A JOINT RESEARCH AGREEMENT

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INCORPORATION BY REFERENCE OF MATERIAL SUBMITTED ON A COMPACT DISC

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BACKGROUND

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BRIEF SUMMARY OF THE INVENTION

Embodiments herein are directed to methods of accurately measuring carcinoembryonic antigen in a biological sample, the method comprising: diluting the biological sample with a diluent to form a diluted sample when an amylase level in the biological sample is less than a pre-determined amylase threshold between about 10,000 and about 20,000 units; wherein diluting the biological sample with a diluent comprises diluting the biological sample in a ratio of biological sample to diluent between about 1:10 and about 1:50; and measuring carcinoembryonic antigen in the diluted sample.

Some embodiments further comprise measuring amylase levels in a biological sample. In some embodiments, the biological sample is undiluted. In some embodiments, the diluent is saline, Diluent Universal, or a combination thereof. In some embodiments, the biological sample is selected from pancreatic fluid, pancreatic cyst fluid and combinations thereof. In some embodiments, the pre-determined amylase threshold is about 10,000 units, about 15,000 units, or about 20,000 units.

In some embodiments, diluting the biological sample with a diluent comprises diluting the biological sample with a diluent in a ratio of biological sample to diluent of about 1:40. In some embodiments, diluting the biological sample with a diluent comprises diluting the biological sample with diluent in a ratio of biological sample to diluent of about 1:10.

In some embodiments, the biological sample is not present in sufficient volume to accurately measure carcinoembryonic antigen levels. In some embodiments, the biological sample has a high viscosity. In some embodiments, the high viscosity is due to the presence of mucin in the biological sample. In some embodiments, the carcinoembryonic antigen levels in the biological sample exceed the measurement capabilities of an instrument being used to measure carcinoembryonic antigen levels.

In some embodiments, the presence of carcinoembryonic antigen above a predetermined carcinoembryonic antigen threshold in the diluted sample is indicative of a pathological condition. In some embodiments, the carcinoembryonic antigen level threshold is about 192 ng/ml, or about 400 ng/ml. In some embodiments, the pathological condition is selected from a neoplastic condition, a non-neoplastic condition and a combination thereof. In some embodiments, the neoplastic condition is selected from colorectal carcinoma, gastric carcinoma, pancreatic carcinoma, cholangiocarcinoma, intraductal papillary mucinous neoplasm (IPMN), lung carcinoma, breast carcinoma, medullary thyroid carcinoma, mucinous cystic neoplasm, and combinations thereof. In some embodiments, the non-neoplastic condition is selected from ulcerative colitis, pancreatitis, pancreatic cysts, pancreatic masses, biliary strictures, cirrhosis, chronic obstructive pulmonary disease, Crohn's disease, intraductal papillary mucinous neoplasm (IPMN), and combinations thereof.

Some embodiments are directed to methods of accurately measuring carcinoembryonic antigen in a biological sample, the method comprising: diluting the biological sample with a diluent at a ratio of biological sample to diluent of about 1:10 to about 1:50 to form a diluted biological sample, wherein the amylase level in the biological sample is greater than a pre-determined amylase threshold between about 10,000 and about 20,000 units; measuring carcinoembryonic antigen level in the diluted biological sample; multiplying the carcinoembryonic antigen level by a correction factor to obtain a corrected carcinoembryonic antigen level.

Some embodiments further comprise measuring amylase levels in a biological sample. In some embodiments, the diluent is saline, Diluent Universal, or a combination thereof. In some embodiments, the biological sample is undiluted. In some embodiments, the biological sample is selected from pancreatic fluid, pancreatic cyst fluid and combinations thereof.

In some embodiments, the pre-determined amylase threshold is about 10,000 units, about 15,000 units, or about 20,000 units. In some embodiments, diluting the biological sample with a diluent comprises diluting the biological sample in a ratio of biological sample to saline of about 1:10. In some embodiments, diluting the biological sample with a diluent comprises diluting the biological sample in a ratio of biological sample to diluent of about 1:40. In some embodiments, the correction factor is about 0.7.

In some embodiments, the biological sample is not present in sufficient volume to accurately measure carcinoembryonic antigen level. In some embodiments, the biological sample has a high viscosity. In some embodiments, the high viscosity is due to the presence of mucin in the biological sample. In some embodiments, the carcinoembryonic antigen levels in the biological sample exceed the measurement capabilities of an instrument being used to measure carcinoembryonic antigen level.

In some embodiments, a corrected carcinoembryonic antigen level above a predetermined carcinoembryonic antigen threshold is indicative of a pathological condition. In some embodiments, the carcinoembryonic antigen level threshold is about 192 ng/ml, or about 400 ng/ml. In some embodiments, the pathological condition is selected from a neoplastic condition, a non-neoplastic condition and a combination thereof. In some embodiments, the neoplastic condition is selected from colorectal carcinoma, gastric carcinoma, cholangiocarcinoma, pancreatic carcinoma, intraductal papillary mucinous neoplasm (IPMN), lung carcinoma, breast carcinoma, medullary thyroid carcinoma, mucinous cystic neoplasm, and combinations thereof. In some embodiments, the non-neoplastic condition is selected from ulcerative colitis, pancreatitis, pancreatic cysts, pancreatic masses, biliary strictures, cirrhosis, chronic obstructive pulmonary disease, Crohn's disease, intraductal papillary mucinous neoplasm (IPMN), and combinations thereof.

Some embodiments are directed to methods of identifying a mucinous cyst in a subject, the method comprising: diluting the biological sample with a diluent when an amylase level in the biological sample is less than a pre-determined amylase threshold between about 10,000 and about 20,000 units, to form a diluted sample, wherein diluting the biological sample with a diluent comprises diluting the biological sample in a ratio of biological sample to diluent between about 1:10 and about 1:50; and measuring carcinoembryonic antigen level in the diluted sample; wherein a carcinoembryonic antigen level above a predetermined carcinoembryonic antigen level threshold in the diluted sample is indicative of a mucinous cyst.

Some embodiments further comprise obtaining a biological sample from the subject. In some embodiments, the diluent is saline, Diluent Universal, or a combination thereof. In some embodiments, the biological sample is selected from pancreatic fluid, pancreatic cyst fluid and combinations thereof. Some embodiments further comprise measuring amylase levels in a biological sample. In some embodiments, the biological sample is undiluted.

In some embodiments, the pre-determined amylase threshold is about 10,000 units, about 15,000 units, or about 20,000 units. In some embodiments, diluting the biological sample with a diluent comprises diluting the biological sample in a ratio of biological sample to diluent of about 1:40. In some embodiments, diluting the biological sample with a diluent comprises diluting the biological sample in a ratio of biological sample to diluent of about 1:10.

In some embodiments, the biological sample is not present in sufficient volume to accurately measure carcinoembryonic antigen levels. In some embodiments, the biological sample has a high viscosity. In some embodiments, the high viscosity is due to the presence of mucin in the neat biological sample. In some embodiments, the carcinoembryonic antigen levels in the biological sample exceed the measurement capabilities of an instrument being used to measure carcinoembryonic antigen.

In some embodiments, the carcinoembryonic antigen level threshold is about 192 ng/ml, or about 400 ng/ml.

Some embodiments are directed to methods of identifying a mucinous cyst in a subject, the method comprising: diluting the biological sample with a diluent at a ratio of biological sample to diluent of about 1:10 to about 1:50 to form a diluted biological sample, wherein the amylase levels in the biological sample are greater than a pre-determined amylase threshold between about 10,000 and about 20,000 units; measuring carcinoembryonic antigen level in the diluted biological sample; multiplying the carcinoembryonic antigen level of the diluted biological sample by a correction factor to obtain a corrected carcinoembryonic antigen level, wherein the carcinoembryonic antigen level in the diluted biological sample is less than the carcinoembryonic antigen levels in an aliquot of the same biological sample diluted with diluent in a ratio of biological sample to diluent of about 1:10; and wherein a corrected carcinoembryonic antigen level of above a predetermined carcinoembryonic antigen threshold is indicative of a mucinous cyst.

Some embodiments further comprise obtaining a biological sample from the subject. In some embodiments, the diluent is saline, Diluent Universal, or a combination thereof. Some embodiments further comprise measuring amylase levels in a biological sample. In some embodiments, the biological sample is undiluted. In some embodiments, the biological sample is selected from pancreatic fluid, pancreatic cyst fluid and combinations thereof.

In some embodiments, the pre-determined amylase threshold is about 10,000 units, about 15,000 units, or about 20,000 units. In some embodiments, diluting the biological sample with a diluent comprises diluting the biological sample in a ratio of biological sample to diluent of about 1:10. In some embodiments, diluting the biological sample with diluent comprises diluting the biological sample in a ratio of biological sample to diluent of about 1:40. In some embodiments, the correction factor is about 0.7. In some embodiments, the carcinoembryonic antigen level threshold is about 192 ng/ml or about 400 ng/ml.

In some embodiments, the biological sample is not present in sufficient volume to accurately measure carcinoembryonic antigen. In some embodiments, the biological sample has a high viscosity. In some embodiments, the high viscosity is due to the presence of mucin in the neat biological sample. In some embodiments, the carcinoembryonic antigen levels in the biological sample exceed the measurement capabilities of an instrument being used to measure carcinoembryonic antigen.

DESCRIPTION OF DRAWINGS

FIG. 1 shows neat carcinoembryonic antigen (CEA) levels in pancreatic cyst fluid samples plotted against CEA levels in pancreatic cyst fluid samples diluted with saline at a ratio of sample to saline of 1:10. Samples are plotted based on amylase levels (e.g. less than 10,000, 15,000, 20,000, 25,000, 30,000 or 40,000)

FIG. 2 shows neat carcinoembryonic antigen (CEA) levels in pancreatic cyst fluid samples plotted against CEA levels in pancreatic cyst fluid samples diluted with saline at a ratio of sample to saline of 1:10 or with Diluent Universal at a ratio of sample to diluent of 1:10. Samples are plotted based on amylase levels (e.g. greater than 15,000, 20,000, 25,000, 30,000 or 40,000).

FIG. 3 shows neat carcinoembryonic antigen (CEA) levels in pancreatic cyst fluid samples plotted against CEA levels in pancreatic cyst fluid samples diluted with saline at a ratio of sample to saline of 1:10 or with Diluent Universal at a ratio of sample to diluent of 1:10 for samples with amylase levels greater than 55,000, 60,000, 65,000, 70,000, 75,000 or 80,000. Samples are plotted based on amylase levels.

FIG. 4 shows the effect of different correction factors after 1:10 dilution with saline of pancreatic cyst fluid with amylase values greater than15,000 on the ability (accuracy, sensitivity, and specificity) to detect mucinous pancreatic cysts with CEA values of greater than or equal to 192, which can be indicative of the presence of a mucinous cyst.

FIG. 5 shows the correlation of carcinoembryonic antigen (CEA) levels in 266 undiluted cyst fluid samples versus CEA levels in cyst fluid samples diluted 1:10 with Diluent Universal (top graph) and 1:10 with Diluent Universal followed by application of a correction factor of 0.7 for samples with amylase levels of greater than 15,000 (bottom graph). The intraclass correlation coefficient (ICC) using Diluent Universal=0.32 (0.63 without outlier data point) and intraclass correlation coefficient (ICC) using Diluent Universal followed by application of a correction factor of 0.7=0.33 (0.80 without outlier data point). Black crosses represent samples with amylase levels equal to, or below 15,000 and gray crosses represent samples with amylase levels greater than 15,000.

FIG. 6 shows the correlation of carcinoembryonic antigen (CEA) levels in 266 undiluted cyst fluid samples versus CEA levels in cyst fluid samples diluted 1:10 with saline (top graph) and 1:10 with saline followed by application of a correction factor of 0.7 for samples with amylase levels of greater than 15,000 (bottom graph). The intraclass correlation coefficient (ICC) using saline=0.73 and intraclass correlation coefficient (ICC) using saline followed by application of a correction factor of 0.7=0.84. Black crosses represent samples with amylase levels equal to or below 15,000 and gray crosses represent samples with amylase levels greater than 15,000.

FIG. 7 shows Bland-Altman bias plots examining a ratio of undiluted sample CEA levels to diluted sample CEA levels (diluted 1:10 with Diluent Universal) showing statistically significant bias (top graph; bias with outlier data point=0.6553449, p-value <2.2e-16; bias without outlier data point =0.6605572, p-value <2.2e-16), and examined using a ratio of undiluted sample CEA levels to diluted sample CEA levels (diluted 1:10 with Diluent Universal followed by application of a correction factor of 0.7 for samples with amylase levels of greater than 15,000) showing a statistically significant but reduced bias (bottom graph; bias with outlier data point=0.7864442, p-value <2.2e-16; bias without outlier data point =0.7932449, p-value <2.2e-16). Black crosses represent samples with amylase levels equal to or below 15,000 and gray crosses represent samples with amylase levels greater than 15,000.

FIG. 8 shows Bland Altman bias plots examining a ratio of undiluted sample CEA levels to diluted sample CEA levels (diluted 1:10 with saline) showing statistically significant bias (top graph; bias=0.8304916, p-value=6.115e-11), and examined using a ratio of undiluted sample CEA levels to diluted sample CEA levels (diluted 1:10 with saline followed by application of a correction factor of 0.7 for samples with amylase levels of greater than 15,000) showing no statistically significant bias (bottom graph; bias=0.9966283, p-value=0.8881). Black crosses represent samples with amylase levels equal to or below 15,000 and gray crosses represent samples with amylase levels greater than 15,000.

DETAILED DESCRIPTION

Imaging techniques, cytology, and biochemical analysis including carcinoembryonic antigen (CEA) concentrations of pancreatic cyst fluid obtained by endoscopic ultrasound-guided fine needle aspiration are used to differentiate pancreatic cyst lesions, particularly those with malignant potential. The American College of Gastroenterology guidelines have outlined the published data relating to the diagnostic performance of pancreatic cyst fluid CEA and concluded that cyst fluid CEA is the single most important factor in determining pancreatic cyst etiology.

In practice, more than 60% of pancreatic cyst and duct fluid CEA testing requires preliminary sample dilution due to i) low aspirated fluid volume, ii) high sample viscosity, and/or iii) initial elevated CEA beyond instrument measureable range (IMR). There are concerns over the fact that CEA measurements in cyst fluid diluted with aqueous salt solutions or water do not accurately reflect the original, undiluted cyst fluid measurement. Disclosed herein are novel methods that provide a more accurate measurement of CEA in diluted pancreatic cyst fluid.

Methods of Accurately Measuring Carcinoembryonic Antigen

Embodiments herein are directed to methods of accurately measuring carcinoembryonic antigen in a biological sample, the method comprising: diluting the biological sample with a diluent to form a diluted sample when an amylase level in the biological sample is less than a pre-determined amylase threshold between about 10,000 and about 20,000 units; wherein diluting the biological sample with a diluent comprises diluting the biological sample in a ratio of biological sample to diluent between about 1:10 and about 1:50; and measuring carcinoembryonic antigen in the diluted sample. Some embodiments further comprise measuring amylase level in a biological sample. In some embodiments, the biological sample is undiluted. In some embodiments, the biological sample is selected from pancreatic fluid, pancreatic cyst fluid and combinations thereof. In some embodiments, the pre-determined amylase threshold is about 10,000 units, about 15,000 units, or about 20,000 units. In some embodiments, diluting the biological sample with a diluent comprises diluting the biological sample with diluent in a ratio of biological sample to diluent of about 1:40. In some embodiments, diluting the biological sample with a diluent comprises diluting the biological sample with a diluent in a ratio of biological sample to diluent of about 1:10. In some embodiments, the diluent is an aqueous salt solution. Examples of suitable aqueous salt solutions include but are not limited to saline, Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics), Tyrode's solution, lactated Ringer's Solution, acetated Ringer's solution, TRIS-buffered saline (TBS), Hank's balanced salt solution (HBSS), Earle's balanced salt solution (EBSS), Standard saline citrate (SSC), HEPES-buffered saline (HBS), Gey's balanced salt solution (GBSS), minimum essential medium Eagle alpha modification (α-MEM), phosphate buffered saline (PBS), and combinations thereof. In some embodiments, the biological sample is diluted in water. In some embodiments, the diluent is saline. In some embodiments, the diluent is Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics).

In some embodiments, the biological sample is not present in sufficient volume to accurately measure carcinoembryonic antigen levels. In some embodiments, the minimum volume to accurately measure CEA is about 200 μL. In some embodiments, the biological sample has a high viscosity. In some embodiments, the high viscosity is due to the presence of mucin in the biological sample. In some embodiments, the carcinoembryonic antigen levels in the biological sample exceed the measurement capabilities of an instrument being used to measure carcinoembryonic antigen levels. In some embodiments, measuring CEA comprises measuring CEA with a Roche Modular Analytics E170 instrument.

In some embodiments, the biological sample is selected from pancreatic fluid, pancreatic cyst fluid and combinations thereof. In some embodiments, the presence of carcinoembryonic antigen above a predetermined carcinoembryonic antigen threshold in the diluted sample is indicative of a pathological condition. In some embodiments, the carcinoembryonic antigen level threshold is between about 5 ng/ml and about 1,000 ng/ml. In some embodiments, the carcinoembryonic antigen level threshold is about 192 ng/ml, or about 400 ng/ml. In yet other embodiments, the carcinoembryonic antigen level threshold is determined based on clinical relevance, by the treating physician or a combination thereof.

In some embodiments, the pathological condition is selected from a neoplastic condition, a non-neoplastic condition and a combination thereof. In some embodiments, the neoplastic condition is selected from colorectal carcinoma, gastric carcinoma, pancreatic carcinoma, cholangiocarcinoma, intraductal papillary mucinous neoplasm (IPMN), lung carcinoma, breast carcinoma, medullary thyroid carcinoma, mucinous cystic neoplasm, and combinations thereof.

In some embodiments, the non-neoplastic condition is selected from ulcerative colitis, pancreatitis, pancreatic cysts, pancreatic masses, biliary strictures, cirrhosis, chronic obstructive pulmonary disease, Crohn's disease, intraductal papillary mucinous neoplasm (IPMN), and combinations thereof.

FIG. 1 depicts neat carcinoembryonic antigen (CEA) levels in pancreatic cyst fluid samples plotted against CEA levels in pancreatic cyst fluid samples diluted with saline at a ratio of sample to saline of 1:10 at a variety of amylase levels (less than 40,000, 30,000, 25,000, 25,000, 20,000, 15,000 or 10,000). FIG. 2 depicts neat carcinoembryonic antigen (CEA) levels in pancreatic cyst fluid samples plotted against CEA levels in pancreatic cyst fluid samples diluted with saline at a ratio of sample to saline of 1:10 or with Diluent Universal at a ratio of sample to diluent of 1:10 for samples with amylase levels above 15,000, 20,000, 25,000, 30,000, or 40,000. FIG. 3 depicts neat carcinoembryonic antigen (CEA) levels in pancreatic cyst fluid samples plotted against CEA levels in pancreatic cyst fluid samples diluted with saline at a ratio of sample to saline of 1:10 or with Diluent Universal at a ratio of sample to diluent of 1:10 for samples with amylase levels above 55,000, 60,000, 65,000, 70,000, 75,000, or 80,000. Applying a correction factor of around 0.7 to CEA measurements of cyst fluid specimens with amylase values greater than 15000 proved most accurate and sensitive for detection of mucinous cysts when a mucinous cyst is deemed present based on CEA levels greater than or equal to 192 ng/mL. In some embodiments, when amylase levels are low (less than 15,000 units), samples diluted with a diluent such as but not limited to saline or Diluent Universal at a ratio of sample to diluent of 1:10 results in CEA level measurements that are comparable to those in neat pancreatic cyst fluid samples. As can be seen in FIGS. 1, 2, and 3, CEA levels in pancreatic cyst fluid samples diluted with saline at a ratio of sample to saline of 1:10 with amylase levels below 20,000 display a high degree of accuracy to neat carcinoembryonic antigen (CEA) levels in pancreatic cyst fluid samples. In contrast, CEA levels in pancreatic cyst fluid samples diluted with saline at a ratio of sample to saline of 1:10 with amylase levels above 20,000 display a lesser degree of accuracy to neat carcinoembryonic antigen (CEA) levels in pancreatic cyst fluid samples. The higher the amylase level in a sample, the less accurate the CEA level reading when the sample is diluted with saline at a ratio of sample to saline of 1:10 compared with neat carcinoembryonic antigen (CEA) levels in pancreatic cyst fluid samples. When amylase levels are high (greater than 15,000 units), CEA levels in samples diluted with a diluent such as but not limited to saline or Diluent Universal at a ratio of sample to saline of 1:10 appear to overestimate CEA values compared with undiluted samples. A linear regression analysis of CEA levels from undiluted, neat samples versus CEA levels in samples diluted in saline at a sample to saline ratio of 1:10 reveals that a correction factor of about 0.7 increases accuracy of CEA level measurements in samples with amylase levels greater than 15,000 units. In addition, FIG. 4 shows that a correction factor of 0.7 results in the best accuracy and specificity. In some embodiments, the CEA level obtained in the sample diluted with saline in a sample to saline ratio of 1:10 is multiplied by the correction factor. In some embodiments the correction factor is about 0.7.

In some embodiments, the methods disclosed herein result in an improved intraclass correlation coefficient. FIG. 5 shows the correlation of carcinoembryonic antigen (CEA) levels in 266 undiluted samples versus CEA levels in samples diluted 1:10 with Diluent Universal (top graph) and 1:10 with Diluent Universal followed by application of a correction factor of 0.7 for samples with amylase levels of greater than 15,000 (bottom graph). The intraclass correlation coefficient (ICC) using Diluent Universal was 0.32 (0.63 without outlier data point) and intraclass correlation coefficient (ICC) using saline followed application of a correction factor of 0.7 was 0.33 (0.80 without outlier data point).

Bland-Altman bias plots were created examining a ratio of undiluted sample CEA levels to diluted sample CEA levels. A bias score of 1 indicated no bias. As can be seen in FIG. 7, the mean bias for cyst fluid samples diluted 1:10 with Diluent Universal was 0.6553449 (p-value <2.2e-16) (Without outlier data point, bias was 0.6605572, p-value <2.2e-16) indicative of a statistically significant bias (top graph). In comparison, the mean bias for cyst fluid samples diluted 1:10 with Diluent Universal followed by application of a correction factor of 0.7 when amylase levels are greater than 15,000 was 0.7864442 (p-value <2.2e-16) (without outlier, bias was 0.7932449 (p-value <2.2e-16)) indicative of a statistically significant but reduced bias (bottom graph).

FIG. 6 shows the correlation of carcinoembryonic antigen (CEA) levels in 266 undiluted samples versus CEA levels in samples diluted 1:10 with saline (top graph) and 1:10 with saline followed application of a correction factor of 0.7 for samples with amylase levels of greater than 15,000 (bottom graph). The intraclass correlation coefficient (ICC) using saline was 0.73 and the intraclass correlation coefficient (ICC) using saline followed application of a correction factor of 0.7 was 0.84.

Bland-Altman bias plots were created examining a ratio of undiluted sample CEA levels to diluted sample CEA levels. A bias score of 1 indicated no bias. As can be seen in FIG. 8, the mean bias for cyst fluid samples diluted 1:10 with saline was 0.8304916 (p-value=6.15 e-11). In comparison, there was no statistically significant bias for cyst fluid samples diluted 1:10 with saline followed by application of a correction factor of 0.7 when amylase levels are greater than 15,000 (0.9966283, p-value=0.8881). These data are indicative that dilution of samples with diluents such as, but not limited to saline and Diluent Universal, followed by application of a correction factor when amylase levels in the sample are greater than 15,000 results in better reproduction of CEA measurements in undiluted samples. These data also indicate that there is decreased variability (increased ICC measurements) and less bias with dilution of samples with diluents such as, but not limited to saline and Diluent Universal followed by application of a correction factor when amylase levels in the sample are greater than 15,000.

In some embodiments, a correction factor is applied when amylase levels in a sample diluted 1:40 with diluent are greater than 15,000. In some embodiments, the correction factor is about 0.7. In some embodiments, the diluent is saline, Diluent Universal or a combination thereof. In some embodiments, a correction factor is applied when amylase levels in a sample diluted 1:10 with diluent are greater than 15,000. In some embodiments, the correction factor is about 0.7. In some embodiments, the diluent is saline, Diluent Universal or a combination thereof. In some embodiments, a correction factor is applied when amylase levels in a sample diluted 1:40 with saline are greater than 15,000. In some embodiments, the correction factor is about 0.7.In some embodiments, a correction factor is applied when amylase levels in a sample diluted 1:10 with saline are greater than 15,000. In some embodiments, the correction factor is about 0.7. Additional studies performed show the correlation of carcinoembryonic antigen (CEA) levels in 72 undiluted samples versus CEA levels in samples diluted 1:10 with saline followed application of a correction factor of 0.7 where amylase levels in diluted samples are greater than 15,000. In this study, results were as follows: ICC=0.91; mean bias=0.94 (p-value=0.139). Yet another study shows the correlation of carcinoembryonic antigen (CEA) levels in 204 undiluted samples versus CEA levels in samples diluted 1:10 with saline followed application of a correction factor of 0.7 where amylase levels in diluted samples are greater than 15,000. In this study, results were as follows: ICC=0.88; mean bias=1.04 (p-value=0.0996) indicating improved variability and no bias when 1:10 dilution is used followed by application of a correction factor of 0.7 in samples with amylase levels above 15,000. Table 1 illustrates the results from the studies described herein for various methods of analyzing CEA levels and results indicate that using an amylase cut off of 15,000 and a sample to saline dilution of 1:10 to 1:40 wherein a correction factor of 0.7 is applied to samples with amylase levels above 15,000 resulted in the superior results and more accurate CEA measurements compared to not implementing the correction factor based on the 15,000 amylase cut off.

TABLE 1 Summary of ICC and Bias for each method of dilution compared to neat CEA values based on not applying (rows 1 and 2) or applying (rows 3 and 4) the correction factor of 0.7 based on Amylase cut off of 15,000 for specimens diluted 1:10 or 1:40 with saline or diluent universal (UD). Training Set Verification Set w/ out outlier Row # ICC Bias p-value ICC Bias p-value 1 Neat vs. 1:10 Saline 0.87 0.78 9.24E−06 0.79 0.87 1.54E−05 2 Neat vs. 1:10 UD Not Not Not Done Not Not Done Not Done Done Done Done 3 Amylase cut-off 0.89 0.98 7.37E−01 0.84 1.13 1.52E−04 (1:40) & CF 0.7 4 Amylase cut-off 0.91 0.94 1.39E−01 0.88 1.04 9.96E−02 (1:10) & CF 0.7

In some embodiments, where amylase levels in a particular sample are below 15,000, the sample is diluted with a diluent at a sample to diluent ratio of 1:40 but no correction factor is used. In some embodiments, where amylase levels in a particular sample are below 15,000, the sample is diluted with a diluent at a sample to diluent ratio of 1:10 but no correction factor is used.

Some embodiments are directed to methods of accurately measuring carcinoembryonic antigen in a biological sample, the method comprising: diluting the biological sample with a diluent at a ratio of biological sample to diluent of about 1:10 to about 1:50 to form a diluted biological sample, wherein the amylase level in the biological sample is greater than a pre-determined amylase threshold between about 10,000 and about 20,000 units; measuring carcinoembryonic antigen level in the diluted biological sample; multiplying the carcinoembryonic antigen level by a correction factor to obtain a corrected carcinoembryonic antigen level. In some embodiments, the correction factor is about 0.7.

In some embodiments, the correction factor applied may vary. In some embodiments, the correction factor to be applied may range from about 0.1 to about 0.8. In some embodiments, the correction factor to be applied when CEA levels greater than 15,000 is about 0.7. In some embodiments the correction factor to be applied is determined as follows: a separate linear regression without intercept may be performed by regressing undiluted CEA (neat) values versus CEA values for samples diluted in diluent at a sample to diluent ratio of about 1:10 for subsets of samples where amylase levels is greater than about 15,000. The resulting estimated coefficient from the above-described linear regressions can be used as the correction factor measurement of CEA levels in a sample diluted with diluent at a sample to diluent ratio of 1:10. In some embodiments, the diluent is an aqueous salt solution. Examples of suitable aqueous salt solutions include but are not limited to saline, Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics), Tyrode's solution, lactated Ringer's Solution, acetated Ringer's solution, TRIS-buffered saline (TBS), Hank's balanced salt solution (HBSS), Earle's balanced salt solution (EBSS), Standard saline citrate (SSC), HEPES-buffered saline (HBS), Gey's balanced salt solution (GBSS), minimum essential medium Eagle alpha modification (α-MEM), phosphate buffered saline (PBS), and combinations thereof. In some embodiments, the biological sample is diluted in water. In some embodiments, the diluent is saline. In some embodiments, the diluent is Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics).

In some embodiments the correction factor to be applied is determined as follows: a separate linear regression without intercept may be performed by regressing undiluted CEA (neat) values versus CEA values for samples diluted in a diluent at a sample to diluent ratio of about 1:40 for subsets of samples where amylase levels is greater than about 15,000. The resulting estimated coefficient from the above-described linear regressions can be used as the correction factor measurement of CEA levels in a sample diluted with diluent at a sample to diluent ratio of 1:40. In some embodiments, the diluent is an aqueous salt solution. Examples of suitable aqueous salt solutions include but are not limited to saline, Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics), Tyrode's solution, lactated Ringer's Solution, acetated Ringer's solution, TRIS-buffered saline (TBS), Hank's balanced salt solution (HBSS), Earle's balanced salt solution (EBSS), Standard saline citrate (SSC), HEPES-buffered saline (HBS), Gey's balanced salt solution (GBSS), minimum essential medium Eagle alpha modification (α-MEM), phosphate buffered saline (PBS), and combinations thereof. In some embodiments, the biological sample is diluted in water. In some embodiments, the diluent is saline. In some embodiments, the diluent is Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics).

Some embodiments further comprise measuring amylase levels in a biological sample. In some embodiments, the biological sample is undiluted. In some embodiments, the biological sample is selected from pancreatic fluid, pancreatic cyst fluid and combinations thereof.

In some embodiments, the pre-determined amylase threshold is about 10,000 units, about 15,000 units, or about 20,000 units. In some embodiments, diluting the biological sample with a diluent comprises diluting the biological sample in a ratio of sample to diluent of about 1:10. In some embodiments, diluting the biological sample with a diluent comprises diluting the biological sample in a ratio of sample to diluent of about 1:40. In some embodiments, the diluent is an aqueous salt solution. Examples of suitable aqueous salt solutions include but are not limited to saline, Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics), Tyrode's solution, lactated Ringer's Solution, acetated Ringer's solution, TRIS-buffered saline (TBS), Hank's balanced salt solution (HBSS), Earle's balanced salt solution (EBSS), Standard saline citrate (SSC), HEPES-buffered saline (HBS), Gey's balanced salt solution (GBSS), minimum essential medium Eagle alpha modification (α-MEM), phosphate buffered saline (PBS), and combinations thereof. In some embodiments, the biological sample is diluted in water. In some embodiments, the diluent is saline. In some embodiments, the diluent is Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics).

In some embodiments, the biological sample is not present in sufficient volume to accurately measure carcinoembryonic antigen levels. In some embodiments, the minimum volume to accurately measure CEA is about 200 μL. In some embodiments, the biological sample has a high viscosity. In some embodiments, the high viscosity is due to the presence of mucin in the biological sample. In some embodiments, the carcinoembryonic antigen levels in the biological sample exceed the measurement capabilities of an instrument being used to measure carcinoembryonic antigen levels. In some embodiments, measuring CEA comprises measuring CEA with a Roche Modular Analytics E170 instrument.

In some embodiments, a corrected carcinoembryonic antigen level above a predetermined carcinoembryonic antigen threshold is indicative of a pathological condition. In some embodiments, the carcinoembryonic antigen level threshold is between about 5 ng/ml and about 1,000 ng/ml. In some embodiments, the carcinoembryonic antigen level threshold is about 192 ng/ml, or about 400 ng/ml. In some embodiments, the pathological condition is selected from a neoplastic condition, a non-neoplastic condition and a combination thereof. In some embodiments, the neoplastic condition is selected from colorectal carcinoma, gastric carcinoma, cholangiocarcinoma, pancreatic carcinoma, intraductal papillary mucinous neoplasm (IPMN), lung carcinoma, breast carcinoma, medullary thyroid carcinoma, mucinous cystic neoplasm, and combinations thereof. In some embodiments, the non-neoplastic condition is selected from ulcerative colitis, pancreatitis, pancreatic cysts, pancreatic masses, biliary strictures, cirrhosis, chronic obstructive pulmonary disease, Crohn's disease, intraductal papillary mucinous neoplasm (IPMN), and combinations thereof.

Methods of Identifying a Mucinous Cyst

Some embodiments are directed to methods of identifying a mucinous cyst in a subject, the method comprising: diluting the biological sample with a diluent when an amylase level in the biological sample is less than a pre-determined amylase threshold between about 10,000 and about 20,000 units, to form a diluted sample, wherein diluting the biological sample with a diluent comprises diluting the biological sample in a ratio of biological sample to diluent between about 1:10 and about 1:50; and measuring carcinoembryonic antigen level in the diluted sample; wherein a carcinoembryonic antigen level above a predetermined carcinoembryonic antigen level threshold in the saline diluted sample is indicative of a mucinous cyst.

Some embodiments further comprise obtaining a biological sample from the subject. In some embodiments, the biological sample is selected from pancreatic fluid, pancreatic cyst fluid and combinations thereof. Some embodiments further comprise measuring amylase levels in a biological sample. In some embodiments, the biological sample is undiluted.

In some embodiments, the pre-determined amylase threshold is about 10,000 units, about 15,000 units, or about 20,000 units. In some embodiments, diluting the biological sample with diluent comprises diluting the biological sample in a ratio of sample to diluent of about 1:40. In some embodiments, diluting the biological sample with a diluent comprises diluting the biological sample in a ratio of sample to diluent of about 1:10. In some embodiments, the diluent is an aqueous salt solution. Examples of suitable aqueous salt solutions include but are not limited to saline, Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics), Tyrode's solution, lactated Ringer's Solution, acetated Ringer's solution, TRIS-buffered saline (TBS), Hank's balanced salt solution (HBSS), Earle's balanced salt solution (EBSS), Standard saline citrate (SSC), HEPES-buffered saline (HBS), Gey's balanced salt solution (GBSS), minimum essential medium Eagle alpha modification (α-MEM), phosphate buffered saline (PBS), and combinations thereof. In some embodiments, the biological sample is diluted in water. In some embodiments, the diluent is saline. In some embodiments, the diluent is Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics).

In some embodiments, the carcinoembryonic antigen level threshold is between about 5 ng/ml and about 1,000 ng/ml. In some embodiments, the carcinoembryonic antigen level threshold is about 192 ng/ml, or about 400 ng/ml.

In some embodiments, the biological sample is not present in sufficient volume to accurately measure carcinoembryonic antigen levels. In some embodiments, the biological sample has a high viscosity. In some embodiments, the high viscosity is due to the presence of mucin in the neat biological sample. In some embodiments, the carcinoembryonic antigen levels in the biological sample exceed the measurement capabilities of an instrument being used to measure carcinoembryonic antigen.

Some embodiments are directed to methods of identifying a mucinous cyst in a subject, the method comprising: diluting the biological sample with a diluent at a ratio of biological sample to diluent of about 1:10 to about 1:50 to form a diluted biological sample, wherein the amylase levels in the biological sample are greater than a pre-determined amylase threshold between about 10,000 and about 20,000 units; measuring carcinoembryonic antigen level in the diluted biological sample; multiplying the carcinoembryonic antigen level of the diluted biological sample by a correction factor to obtain a corrected carcinoembryonic antigen level, and wherein a corrected carcinoembryonic antigen level of above a predetermined carcinoembryonic antigen threshold is indicative of a mucinous cyst. In some embodiments, the correction factor is about 0.7.

Some embodiments further comprise obtaining a biological sample from the subject. Some embodiments further comprise measuring amylase levels in a biological sample. In some embodiments, the biological sample is undiluted. In some embodiments, the biological sample is selected from pancreatic fluid, pancreatic cyst fluid and combinations thereof.

In some embodiments, the pre-determined amylase threshold is about 10,000 units, about 15,000 units, or about 20,000 units. In some embodiments, diluting the biological sample with a diluent comprises diluting the biological sample in a ratio of biological sample to diluent of about 1:10. In some embodiments, diluting the biological sample with diluent comprises diluting the biological sample in a ratio of sample to diluent of about 1:40. In some embodiments, the biological sample can be diluted in an aqueous salt solution. In some embodiments, the diluent is an aqueous salt solution. Examples of suitable aqueous salt solutions include but are not limited to saline, Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics), Tyrode's solution, lactated Ringer's Solution, acetated Ringer's solution, TRIS-buffered saline (TBS), Hank's balanced salt solution (HBSS), Earle's balanced salt solution (EBSS), Standard saline citrate (SSC), HEPES-buffered saline (HBS), Gey's balanced salt solution (GBSS), minimum essential medium Eagle alpha modification (α-MEM), phosphate buffered saline (PBS), and combinations thereof. In some embodiments, the biological sample is diluted in water. In some embodiments, the diluent is saline. In some embodiments, the diluent is Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics).

In some embodiments, the carcinoembryonic antigen level threshold is between about 5 ng/ml and about 1,000 ng/ml. In some embodiments, the carcinoembryonic antigen level threshold is about 192 ng/ml or about 400 ng/ml.

In some embodiments, the biological sample is not present in sufficient volume to accurately measure carcinoembryonic antigen levels. In some embodiments, the minimum volume to accurately measure CEA is about 200 μL. In some embodiments, the biological sample has a high viscosity. In some embodiments, the high viscosity is due to the presence of mucin in the biological sample. In some embodiments, the carcinoembryonic antigen levels in the biological sample exceed the measurement capabilities of an instrument being used to measure carcinoembryonic antigen levels. In some embodiments, measuring CEA comprises measuring CEA with a Roche Modular Analytics E170 instrument.

Methods of Treating a Pathological Condition

Some embodiments are directed to a method of treating a pathological condition in a subject in need thereof, the method comprising measuring CEA in a biological sample from the subject, and administering to the subject an effective amount of a treatment modality for the pathology wherein the presence of CEA in the biological sample is above a pre-determined threshold.

In some embodiments, measuring CEA in a biological sample from the subject comprises diluting the biological sample with a diluent to form a diluted sample when an amylase level in the biological sample is less than a pre-determined amylase threshold between about 10,000 and about 20,000 units; wherein diluting the biological sample with diluent comprises diluting the biological sample in a ratio of biological sample to diluent between about 1:10 and about 1:50; and measuring carcinoembryonic antigen in the diluted sample. Some embodiments further comprise measuring amylase level in a biological sample. In some embodiments, the pre-determined amylase threshold is about 10,000 units, about 15,000 units, or about 20,000 units.

In some embodiments, the biological sample is undiluted. In some embodiments, the biological sample is selected from pancreatic fluid, pancreatic cyst fluid and combinations thereof. In some embodiments, the biological sample is selected from pancreatic fluid, pancreatic cyst fluid and combinations thereof.

In some embodiments, diluting the biological sample with saline comprises diluting the biological sample with a diluent in a ratio of biological sample to diluent of about 1:40. In some embodiments, diluting the biological sample with a diluent comprises diluting the biological sample with diluent in a ratio of biological sample to diluent of about 1:10. In some embodiments, the diluent is an aqueous salt solution. Examples of suitable aqueous salt solutions include but are not limited to saline, Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics), Tyrode's solution, lactated Ringer's Solution, acetated Ringer's solution, TRIS-buffered saline (TBS), Hank's balanced salt solution (HBSS), Earle's balanced salt solution (EBSS), Standard saline citrate (SSC), HEPES-buffered saline (HBS), Gey's balanced salt solution (GBSS), minimum essential medium Eagle alpha modification (α-MEM), phosphate buffered saline (PBS), and combinations thereof. In some embodiments, the biological sample is diluted in water. In some embodiments, the diluent is saline. In some embodiments, the diluent is Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics).

In some embodiments, the biological sample is not present in sufficient volume to accurately measure carcinoembryonic antigen levels. In some embodiments, the minimum volume to accurately measure CEA is about 200 μL. In some embodiments, the biological sample has a high viscosity. In some embodiments, the high viscosity is due to the presence of mucin in the biological sample. In some embodiments, the carcinoembryonic antigen levels in the biological sample exceed the measurement capabilities of an instrument being used to measure carcinoembryonic antigen levels. In some embodiments, measuring CEA comprises measuring CEA with a Roche Modular Analytics E170 instrument.

In some embodiments, the presence of carcinoembryonic antigen above a predetermined carcinoembryonic antigen threshold in the saline diluted sample is indicative of a pathological condition. In some embodiments, the carcinoembryonic antigen level threshold is between about 5 ng/ml and about 1,000 ng/ml. In some embodiments, the carcinoembryonic antigen level threshold is about 192 ng/ml, or about 400 ng/ml. In some embodiments, the pathological condition is selected from a neoplastic condition, a non-neoplastic condition and a combination thereof. In some embodiments, the neoplastic condition is selected from colorectal carcinoma, gastric carcinoma, pancreatic carcinoma, cholangiocarcinoma, intraductal papillary mucinous neoplasm (IPMN), lung carcinoma, breast carcinoma, medullary thyroid carcinoma, and combinations thereof. In some embodiments, the non-neoplastic condition is selected from ulcerative colitis, pancreatitis, pancreatic cysts, pancreatic masses, biliary strictures, cirrhosis, chronic obstructive pulmonary disease, Crohn's disease, intraductal papillary mucinous neoplasm (IPMN), and combinations thereof.

In some embodiments, measuring CEA in a biological sample from the subject comprises diluting the biological sample with a diluent at a ratio of biological sample to diluent of about 1:10 to about 1:50 to form a diluted biological sample, wherein the amylase level in the biological sample is greater than a pre-determined amylase threshold between about 10,000 and about 20,000 units; measuring carcinoembryonic antigen level in the diluted biological sample; multiplying the carcinoembryonic antigen level by a correction factor to obtain a corrected carcinoembryonic antigen level. In some embodiments, the correction factor is about 0.7.

Some embodiments further comprise measuring amylase levels in a biological sample. In some embodiments, the biological sample is undiluted. In some embodiments, the biological sample is selected from pancreatic fluid, pancreatic cyst fluid and combinations thereof.

In some embodiments, the pre-determined amylase threshold is about 10,000 units, about 15,000 units, or about 20,000 units. In some embodiments, diluting the biological sample with diluent comprises diluting the biological sample in a ratio of sample to diluent of about 1:10. In some embodiments, diluting the biological sample with diluent comprises diluting the biological sample in a ratio of sample to diluent of about 1:40. In some embodiments, the diluent is an aqueous salt solution. Examples of suitable aqueous salt solutions include but are not limited to saline, Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics), Tyrode's solution, lactated Ringer's Solution, acetated Ringer's solution, TRIS-buffered saline (TBS), Hank's balanced salt solution (HBSS), Earle's balanced salt solution (EBSS), Standard saline citrate (SSC), HEPES-buffered saline (HBS), Gey's balanced salt solution (GBSS), minimum essential medium Eagle alpha modification (α-MEM), phosphate buffered saline (PBS), and combinations thereof. In some embodiments, the biological sample is diluted in water. In some embodiments, the diluent is saline. In some embodiments, the diluent is Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics).

In some embodiments, the biological sample is not present in sufficient volume to accurately measure carcinoembryonic antigen levels. In some embodiments, the minimum volume to accurately measure CEA is about 200 μL. In some embodiments, the biological sample has a high viscosity. In some embodiments, the high viscosity is due to the presence of mucin in the biological sample. In some embodiments, the carcinoembryonic antigen levels in the biological sample exceed the measurement capabilities of an instrument being used to measure carcinoembryonic antigen levels. In some embodiments, measuring CEA comprises measuring CEA with a Roche Modular Analytics E170 instrument.

In some embodiments, a corrected carcinoembryonic antigen level above a predetermined carcinoembryonic antigen threshold is indicative of a pathological condition. In some embodiments, the carcinoembryonic antigen level threshold is between about 5 ng/ml and about 1,000 ng/ml. In some embodiments, the carcinoembryonic antigen level threshold is about 192 ng/ml, or about 400 ng/ml. In some embodiments, the pathological condition is selected from a neoplastic condition, a non-neoplastic condition and a combination thereof. In some embodiments, the neoplastic condition is selected from colorectal carcinoma, gastric carcinoma, cholangiocarcinoma, pancreatic carcinoma, intraductal papillary mucinous neoplasm (IPMN), lung carcinoma, breast carcinoma, medullary thyroid carcinoma, mucinous cystic neoplasm, and combinations thereof. In some embodiments, the non-neoplastic condition is selected from ulcerative colitis, pancreatitis, pancreatic cysts, pancreatic masses, biliary strictures, cirrhosis, chronic obstructive pulmonary disease, Crohn's disease, intraductal papillary mucinous neoplasm (IPMN), and combinations thereof.

In some embodiments, the treatment modality comprises surgical resection, chemotherapy, drug therapy, biological therapy, gene therapy, vaccine therapy, radiation therapy, photodynamic therapy, hypothermic therapy, laser therapy and combinations thereof.

Some embodiments are directed to a method of treating pancreatic carcinoma in a subject in need thereof, the method comprisingmeasuring CEA in a biological sample from the subject, and administering to the subject an effective amount of a treatment modality for the pathology wherein the presence of CEA in the biological sample is above a pre-determined threshold.

In some embodiments, measuring CEA in a biological sample from the subject comprises diluting the biological sample with a diluent to form a diluted sample when an amylase level in the biological sample is less than a pre-determined amylase threshold between about 10,000 and about 20,000 units; wherein diluting the biological sample with a diluent comprises diluting the biological sample in a ratio of biological sample to diluent between about 1:10 and about 1:50; and measuring carcinoembryonic antigen in the diluted sample.

Some embodiments further comprise measuring amylase level in a biological sample. In some embodiments, the biological sample is undiluted. In some embodiments, the biological sample is selected from pancreatic fluid, pancreatic cyst fluid and combinations thereof.

In some embodiments, the pre-determined amylase threshold is about 10,000 units, about 15,000 units, or about 20,000 units. In some embodiments, diluting the biological sample with diluent comprises diluting the biological sample with saline in a ratio of biological sample with diluent comprises diluting the biological sample with diluent in a ratio of biological sample to diluent of about 1:40. In some embodiments, diluting the biological sample with diluent comprises diluting the biological sample with diluent in a ratio of biological sample to diluent of about 1:10. In some embodiments, the diluent is an aqueous salt solution. Examples of suitable aqueous salt solutions include but are not limited to saline, Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics), Tyrode's solution, lactated Ringer's Solution, acetated Ringer's solution, TRIS-buffered saline (TBS), Hank's balanced salt solution (HBSS), Earle's balanced salt solution (EBSS), Standard saline citrate (SSC), HEPES-buffered saline (HBS), Gey's balanced salt solution (GBSS), minimum essential medium Eagle alpha modification (α-MEM), phosphate buffered saline (PBS), and combinations thereof. In some embodiments, the biological sample is diluted in water. In some embodiments, the diluent is saline. In some embodiments, the diluent is Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics).

In some embodiments, the biological sample is not present in sufficient volume to accurately measure carcinoembryonic antigen levels. In some embodiments, the minimum volume to accurately measure CEA is about 200 μL. In some embodiments, the biological sample has a high viscosity. In some embodiments, the high viscosity is due to the presence of mucin in the biological sample. In some embodiments, the carcinoembryonic antigen levels in the biological sample exceed the measurement capabilities of an instrument being used to measure carcinoembryonic antigen levels. In some embodiments, measuring CEA comprises measuring CEA with a Roche Modular Analytics E170 instrument.

In some embodiments, the biological sample is selected from pancreatic fluid, pancreatic cyst fluid and combinations thereof. In some embodiments, the presence of carcinoembryonic antigen above a predetermined carcinoembryonic antigen threshold in the saline diluted sample is indicative of pancreatic carcinoma. In some embodiments, the carcinoembryonic antigen level threshold is between about 5 ng/ml and about 1,000 ng/ml. In some embodiments, the carcinoembryonic antigen level threshold is about 192 ng/ml, or about 400 ng/ml.

In some embodiments, measuring CEA in a biological sample from the subject comprises diluting the biological sample with a diluent at a ratio of biological sample to diluent of about 1:10 to about 1:50 to form a diluted biological sample, wherein the amylase level in the biological sample is greater than a pre-determined amylase threshold between about 10,000 and about 20,000 units; measuring carcinoembryonic antigen level in the diluted biological sample; multiplying the carcinoembryonic antigen level by a correction factor to obtain a corrected carcinoembryonic antigen level. In some embodiments, the correction factor is about 0.7.

Some embodiments further comprise measuring amylase levels in a biological sample. In some embodiments, the biological sample is undiluted. In some embodiments, the biological sample is selected from pancreatic fluid, pancreatic cyst fluid and combinations thereof.

In some embodiments, the pre-determined amylase threshold is about 10,000 units, about 15,000 units, or about 20,000 units. In some embodiments, diluting the biological sample with a diluent comprises diluting the biological sample in a ratio of sample to diluent of about 1:10. In some embodiments, diluting the biological sample with saline comprises diluting the biological sample in a ratio of sample to diluent of about 1:40. In some embodiments, the diluent is an aqueous salt solution. Examples of suitable aqueous salt solutions include but are not limited to saline, Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics), Tyrode's solution, lactated Ringer's Solution, acetated Ringer's solution, TRIS-buffered saline (TBS), Hank's balanced salt solution (HBSS), Earle's balanced salt solution (EBSS), Standard saline citrate (SSC), HEPES-buffered saline (HBS), Gey's balanced salt solution (GBSS), minimum essential medium Eagle alpha modification (α-MEM), phosphate buffered saline (PBS), and combinations thereof. In some embodiments, the biological sample is diluted in water. In some embodiments, the diluent is saline. In some embodiments, the diluent is Diluent Universal (Elecsys Diluent Universal, Roche Diagnostics).

In some embodiments, the biological sample is not present in sufficient volume to accurately measure carcinoembryonic antigen levels. In some embodiments, the minimum volume to accurately measure CEA is about 200 μL. In some embodiments, the biological sample has a high viscosity. In some embodiments, the high viscosity is due to the presence of mucin in the biological sample. In some embodiments, the carcinoembryonic antigen levels in the biological sample exceed the measurement capabilities of an instrument being used to measure carcinoembryonic antigen levels. In some embodiments, measuring CEA comprises measuring CEA with a Roche Modular Analytics E170 instrument.

In some embodiments, a corrected carcinoembryonic antigen level above a predetermined carcinoembryonic antigen threshold is indicative of pancreatic carcinoma. In some embodiments, the carcinoembryonic antigen level threshold is between about 5 ng/ml and about 1,000 ng/ml. In some embodiments, the carcinoembryonic antigen level threshold is about 192 ng/ml, or about 400 ng/ml.

In some embodiments, the treatment modality comprises surgical resection, chemotherapy, drug therapy, biological therapy, gene therapy, vaccine therapy, radiation therapy, photodynamic therapy, hypothermic therapy, laser therapy and combinations thereof.

This invention and embodiments illustrating the method and materials used may be further understood by reference to the following non-limiting examples.

EXAMPLES Example 1 Analytical Validation of Dilution of Pancreatic Fluid Specimens for CEA Testing

Purpose

To determine if the New Method for dilution of pancreatic cyst fluid specimens for CEA testing is improved compared to the clinical method through establishing analytical linearity, accuracy, precision, sensitivity and specificity.

Introduction

CEA measurements in diluted pancreatic cyst fluids have been found to not accurately reflect the original neat pancreatic cyst fluid CEA value. RedPath Integrated Pathology has developed a unique testing method to address this issue. A pancreatic cyst fluid is inherently a lower volume specimen type, and often times the volume of the specimen collected does not meet the volume requirement for CEA testing. The ability to perform upfront dilutions on pancreatic cysts specimens and provide an accurate CEA value, as compared to undiluted CEA measurements, was the goal in the development of this methodology improvement.

CEA Method Development

The development process for this methodology evolved through trial and error of different applications and the correlating analyses of each result set. Pancreatic cyst fluids with excess volume were used for all developmental testing of this method, and dilutions performed on specimens were compared to the CEA values obtained from testing the specimens neat (undiluted).

A number of different off-shelf diluents were tested comparatively. During this testing, it was found that Saline showed improvement as a diluent versus Diluent Universal (UD, Roche), which is currently the diluent used to perform dilutions for clinical CEA testing. However, the use of saline alone was not enough to improve the accuracy of the CEA value for all pancreatic cyst fluid specimens when diluted.

An in-house diluent, “Solution CEA”, was developed and tested in effort to improve the accuracy of all diluted pancreatic cyst fluid specimens. This diluent was found to be effective on some specimens but to over perform for certain pancreatic cyst fluid specimens. When specimens were tested in parallel with saline and Solution CEA dilutions the comparative data was reviewed and a pattern evolved with the incorporation of the Amylase results into the analysis. It was determined that specimens with an Amylase value of less than 15,000 were more accurate with the use of saline as a diluent when compared to the neat CEA values. However, specimens with an Amylase value of greater than 15,000 were more accurate with the use of Solution CEA as the diluent when compared to the neat CEA values.

As more testing was conducted to verify the method and increase the “n” of specimens tested, it was identified through statistical analysis that the effect of the Solution CEA as a diluents could be mathematically replicated through the use of a correction factor (CF). Different CFs were trained and tested on varying dilution points. It was found through this testing that it was essential to both train and validate the method on data sets with pancreatic cyst fluids divided proportionately, since differ methods of testing were required for specimens based on the Amylase result (please refer to Validation Methods, below).

New CEA Method for Validation

All pancreatic fluid specimens requiring an upfront dilution will be diluted using saline as the diluent, and will be diluted using a 1:10 dilution point. Any specimen that requires a dilution and has an Amylase value of greater than 15,000 will have a correction factor (CF) of 0.7 applied to the CEA value to determine the final CEA result reported.

Example: Amylase=16,000

CEA value after 1:10 dilution=400 (value after adjusted for dilution factor)

Final CEA Result for 1:10 dilution=400 multiplied by 0.7=280

Validation Methods

Linearity, Accuracy, Sensitivity & Specificity

To validate the method for dilution of pancreatic cyst fluid specimens, parallel specimen testing for CEA was completed. Each specimen was diluted in UD (old method) and saline (new method) with re-testing of CEA & Amylase on a neat specimen aliquot for result comparison. The validation specimen set was comprised of an equal number of specimens divided into 4 categories. These four specimen categories are:

-   -   High CEA (greater than 192) & High Amylase (greater than 15,000)     -   Low CEA (less than 192) & High Amylase (greater than 15,000)     -   High CEA (greater than 192) & Low Amylase (less than 15,000)     -   Low CEA (less than 192) & Low Amylase (less than 15,000)

For this validation, 92 pancreatic cyst fluid specimens were accrued with 23 specimens in each of the four categories described above. Each specimen was accrued and tested as follows:

-   -   1. Daily clinical CEA reaction aliquots and Amylase reaction         aliquots were saved that meet the following:         -   a. A NEAT CEA result of 20-1000         -   b. Reportable Amylase result     -   2. All specimen aliquots were stored at 4 C until parallel         testing was completed.     -   3. For each specimen identified, the following testing was         performed:         -   a. Amylase & CEA (on neat specimen) were re-tested all             remaining specimen volume was saved to perform dilutions             listed below.         -   b. Prepare a 1:10 dilution for CEA using Diluent Universal             -   i. 20 μL of specimen to 180 μL of UD         -   c. Serial Dilution Series “D” for 1:10 & 1:40 dilutions in             Saline were prepared as follows:             -   i. 1:10 dilution for CEA using Saline                 -   (1) 30 μL of specimen to 270 μL of Saline             -   ii. 1:40 dilution using Saline & remaining volume from                 1:10 dilution in Saline                 -   (1) 50 μL of 1:10 in Saline to 150 μL of Saline             -   NOTE: 1:40 not required for this validation.     -   4. Testing was completed as defined by standard operating         procedures for the neat CEA & Amylase re-tests, as well as the         1:10 dilutions in UD and Saline for CEA testing. All testing was         performed on the same day.     -   5. All specimen aliquots, both NEAT and diluted, were stored at         4° C. after testing was completed.     -   6. Specimens were accrued and tested as received.         Precision

To determine precision, pancreatic cyst fluid specimens were collected to perform parallel specimen testing for CEA. Prior to the precision study, each specimen was re-tested for CEA & Amylase using a neat specimen aliquot for result comparison. Parallel testing was performed in triplicate on specimen dilutions in UD (old method) and Saline (new method). Each dilution was tested over 3 different run scenarios:

-   -   Run 1=DAY 1: Operator 1     -   Run 2=DAY 1: Operator 2     -   Run 3=DAY 2: Operator 1

For this validation, 16 specimens were accrued with 4 specimens in each of the four categories described above in the “Linearity, Accuracy, Sensitivity & Specificity” section. Each specimen was accrued and tested as follows:

-   1. Specimens were collected over a period of time that met the     following:     -   a. A NEAT CEA result of 20-1000     -   b. Reportable Amylase result     -   c. At least 650 μL of remaining fluid -   2. Specimens collected were aliquoted, labeled, and stored at 4° C. -   3. Specimens were re-tested to confirm original results prior to     proceeding with Step 4, as follows:     -   a. Re-tested specimens Neat for CEA     -   b. Re-tested specimens for Amylase -   4. Eight specimens with the following (CEA and Amylase clinical     reaction aliquots may have been saved and used to re-test CEA and     Amylase and/or for dilution preparations from NEAT reaction     aliquots):     -   a. Clinical Amylase result=LESS THAN 15,000     -   b. Clinical CEA result=20-1000         -   (1) 4 MED/HIGH specimens (192<CEA<400-1000)         -   (2) 4 LOW specimens (CEA<192) -   5. Eight specimens with the following (CEA and Amylase clinical     reaction aliquots may have been saved and used to re-test CEA and     Amylase and/or for dilution preparations from NEAT reaction     aliquots):     -   a. Clinical Amylase result=GREATER THAN 15,000     -   b. Clinical CEA result=0-1000 (instrument range)         -   (1) 4 MED/HIGH specimens (192<CEA<400-1000)         -   (2) 4 LOW specimens (CEA<192) -   6. For each specimen identified, triplicate tests were run for all     dilution points (see step 7, below) and tested over a 2-day period,     as listed below:     -   a. Run 1=DAY 1: Operator 1     -   b. Run 2=DAY 1: Operator 2     -   c. Run 3=DAY 2: Operator 1 -   7. Dilutions for the identified specimens tested as described in     step 6 are listed below:     -   a. 1:10 dilution for CEA using UD         -   (1) 60 μL of specimen to 540 μL of UD             -   (i) Prepared 3 aliquots (A, B & C) at 200 ul.             -   (ii) 1 Dilution/3 aliquots→3 results     -   b. Serial Dilution Series “D” as follows:         -   (i) 1:10 dilution for CEA using Saline             -   A. 90 μL of specimen to 810 μL of Saline                 -   1. Prepared 3 aliquots (A, B & C) at 200 ul.                 -   2. 1 Dilution/3 aliquots→3 results         -   (ii) 1:40 dilution using Saline & remaining volume from 1:10             dilution in Saline             -   A. 150 μL of 1:10 in Saline to 450 μL of Saline                 -   1. Prepared 3 aliquots (A, B & C) at 200 μL                 -   2. 1 Serial Dilution/3 aliquots→3 results     -   NOTE: 1:40 not required for this validation -   8. Testing was completed as defined by SOPs for the neat re-tests     for CEA & Amylase testing, as well as the 1:10 dilutions in UD and     Saline for CEA testing. All testing was performed on the same day. -   9. All specimen aliquots, both NEAT and diluted, were stored at     4° C. after testing was completed.     Linearity and Accuracy

Intraclass Correlation (ICC), concordance correlation (CC), and bias were used to measure the agreement between CEA values obtained on neat pancreatic fluid specimens versus diluted pancreatic fluid specimens (both old and new dilution methods). See FIGS. 5 and 6.

The concordance for the old and new dilution method compared to neat (undiluted) CEA values were determine when data was analyzed in clinically relevant categories. The categories were defined by using 192 ng/mL as the cut-off between Low CEA and High CEA. A CEA value of 192 ng/mL was selected, because this value has been used to discriminate between mucinous and non-mucinous cysts. Values at or above 192 ng/mL indicate mucinous cysts; values below this cut-off indicate non-mucinous cysts. The concordance with neat CEA values was improved using the New CEA method as compared to the Old CEA method (Table 2).

TABLE 2 Concordance between neat CEA values and diluted CEA values (Old vs. New Method) when data was analyzed in high (>192 ng/mL) and low (<192 ng/mL) CEA categories. Neat CEA values compared to: % Concordance Old method 88.04% New Method 91.30% Sensitivity and Specificity

The sensitivity and specificity for measuring the CEA analyte is described by the manufactures of the Elecsys 2010 CEA analyzer (Roche, REF 11731629, http://www.roche.com.mx/fmfiles/re7143001/ElecsysCEA.pdf). The range in which CEA can be measured by this instrument is 0.200-1000 ng/mL, with 0.200 being the lower limit of detection. Any interfering substances present in pancreatic cyst fluid will be less abundant when dilution in saline occurs.

Precision

Coefficient of variation (CV) was used to assess the reproducibility of CEA values obtained on neat pancreatic fluid specimens versus diluted pancreatic fluid specimens (both old and new dilution methods). Please see Table 3 for the inter-run and intra-run reproducibility of old dilution method and Table 4 for inter-run and intra-run reproducibility of new dilution method.

TABLE 3 Inter-Run & Intra-Run Reproducibility - Old CEA Dilution Method Overall Inter Run 4.16% Overall Intra Run 2.85% MEAN CV MEAN CV Overall Inter Run 4.00% Overall Intra Run 2.16% Median CV Median CV

TABLE 4 Inter-Run Reproducibility - New CEA Dilution Method Overall Inter Run 4.72% Overall Intra Run 2.50% MEAN CV MEAN CV Overall Inter Run 4.67% Overall Intra Run 2.03% Median CV Median CV Validation Conclusions Linearity& Accuracy

There is an increase in agreement between the neat CEA value and the diluted CEA value using the New CEA Dilution method versus the Old CEA dilution method. Intraclass Correlation (ICC), concordance correlation (CC), bias, and categorical concordance between diluted and neat CEA values were all improved using the New CEA dilution method as compared to the Old CEA dilution method.

Sensitivity & Specificity

Sensitivity and Specificity are per the manufacturer's description for the Elecsys 2010 (Roche) instrument CEA analyzer.

Precision

Both methods showed good reproducibility, with the New CEA Dilution method showing a slight improvement in overall intra-run reproducibility. Inter-run reproducibility is generally accepted with CVs of less than 15%; intra-run reproducibility is generally accepted with CVs of less than 10%. All CVs for the New CEA dilution method were less than these values.

The results described above, indicate that the New CEA Dilution method performance is similar to or improved compared to the current clinical method (i.e. Old CEA Dilution method) for pancreatic fluid samples. Therefore the New CEA Dilution method is acceptable for implementation on clinical pancreatic fluid specimens received for CEA testing.

REFERENCES

-   1. Clinical Chemistry 2010; 56; 1351-1352 -   2. Gastroenterol 2004; 126: 1330-1336 -   3. AM J Gastroenterol 2007; 102:2339-2349 -   4.     http://www.salimetrics.com/documents/spit-tips/publications/Inter%20and%20Intra%20Assay%20Coefficients%20of%20Variability.pdf

The present disclosure is not to be limited in terms of the particular embodiments described in this application, which are intended as illustrations of various aspects. Many modifications and variations can be made without departing from its spirit and scope, as will be apparent to those skilled in the art. Functionally equivalent methods and apparatuses within the scope of the disclosure, in addition to those enumerated herein, will be apparent to those skilled in the art from the foregoing descriptions. Such modifications and variations are intended to fall within the scope of the appended claims. The present disclosure is to be limited only by the terms of the appended claims, along with the full scope of equivalents to which such claims are entitled. It is to be understood that this disclosure is not limited to particular methods, reagents, compounds, compositions or biological systems, which can, of course, vary. It is also to be understood that the terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting.

With respect to the use of substantially any plural and/or singular terms herein, those having skill in the art can translate from the plural to the singular and/or from the singular to the plural as is appropriate to the context and/or application. The various singular/plural permutations may be expressly set forth herein for sake of clarity.

It will be understood by those within the art that, in general, terms used herein, and especially in the appended claims (e.g., bodies of the appended claims) are generally intended as “open” terms (e.g., the term “including” should be interpreted as “including but not limited to,” the term “having” should be interpreted as “having at least,” the term “includes” should be interpreted as “includes but is not limited to,” etc.). It will be further understood by those within the art that if a specific number of an introduced claim recitation is intended, such an intent will be explicitly recited in the claim, and in the absence of such recitation no such intent is present. For example, as an aid to understanding, the following appended claims may contain usage of the introductory phrases “at least one” and “one or more” to introduce claim recitations. However, the use of such phrases should not be construed to imply that the introduction of a claim recitation by the indefinite articles “a” or “an” limits any particular claim containing such introduced claim recitation to embodiments containing only one such recitation, even when the same claim includes the introductory phrases “one or more” or “at least one” and indefinite articles such as “a” or “an” (e.g., “a” and/or “an” should be interpreted to mean “at least one” or “one or more”); the same holds true for the use of definite articles used to introduce claim recitations. In addition, even if a specific number of an introduced claim recitation is explicitly recited, those skilled in the art will recognize that such recitation should be interpreted to mean at least the recited number (e.g., the bare recitation of “two recitations,” without other modifiers, means at least two recitations, or two or more recitations). Furthermore, in those instances where a convention analogous to “at least one of A, B, and C, etc.” is used, in general such a construction is intended in the sense one having skill in the art would understand the convention (e.g., “a system having at least one of A, B, and C” would include but not be limited to systems that have A alone, B alone, C alone, A and B together, A and C together, B and C together, and/or A, B, and C together, etc.). In those instances where a convention analogous to “at least one of A, B, or C, etc.” is used, in general such a construction is intended in the sense one having skill in the art would understand the convention (e.g., “a system having at least one of A, B, or C” would include but not be limited to systems that have A alone, B alone, C alone, A and B together, A and C together, B and C together, and/or A, B, and C together, etc.). It will be further understood by those within the art that virtually any disjunctive word and/or phrase presenting two or more alternative terms, whether in the description, claims, or drawings, should be understood to contemplate the possibilities of including one of the terms, either of the terms, or both terms. For example, the phrase “A or B” will be understood to include the possibilities of “A” or “B” or “A and B.”

In addition, where features or aspects of the disclosure are described in terms of Markush groups, those skilled in the art will recognize that the disclosure is also thereby described in terms of any individual member or subgroup of members of the Markush group.

As will be understood by one skilled in the art, for any and all purposes, such as in terms of providing a written description, all ranges disclosed herein also encompass any and all possible subranges and combinations of subranges thereof. Any listed range can be easily recognized as sufficiently describing and enabling the same range being broken down into at least equal halves, thirds, quarters, fifths, tenths, etc. As a non-limiting example, each range discussed herein can be readily broken down into a lower third, middle third and upper third, etc. As will also be understood by one skilled in the art all language such as “up to,” “at least,” and the like include the number recited and refer to ranges, which can be subsequently broken down into subranges as discussed above. Finally, as will be understood by one skilled in the art, a range includes each individual member. Thus, for example, a group having 1-3 substituents refers to groups having 1, 2, or 3 substituents. Similarly, a group having 1-5 substituents refers to groups having 1, 2, 3, 4, or 5 substituents, and so forth. 

What is claimed:
 1. A method of measuring carcinoembryonic antigen in a biological sample, the method comprising: diluting the biological sample with a diluent at a ratio of biological sample to diluent of about 1:10 to about 1:50 to form a diluted biological sample; measuring the amylase level of the diluted biological sample; measuring carcinoembryonic antigen level in the diluted biological sample; and multiplying the carcinoembryonic antigen level by a correction factor to obtain a corrected carcinoembryonic antigen level when the amylase level in the diluted samples is above about 10,000 units.
 2. The method of claim 1, wherein the diluent is saline, Diluent Universal, or a combination thereof.
 3. The method of claim 1, wherein the biological sample is undiluted prior to the diluting step.
 4. The method of claim 1, wherein diluting the biological sample with a diluent comprises diluting the biological sample with a diluent in a ratio of about 1:10.
 5. The method of claim 1, wherein diluting the biological sample with a diluent comprises diluting the biological sample with a diluent in a ratio of about 1:40.
 6. The method of claim 1, wherein the correction factor is about 0.7.
 7. The method of claim 1, wherein the biological sample is not present in sufficient volume to accurately measure carcinoembryonic antigen level.
 8. The method of claim 1, wherein the biological sample has a high viscosity.
 9. The method of claim 8, wherein the high viscosity is due to the presence of mucin in the biological sample.
 10. The method of claim 1, wherein the carcinoembryonic antigen levels in the biological sample exceed the measurement capabilities of an instrument being used to measure carcinoembryonic antigen level.
 11. The method of claim 1, wherein the biological sample is selected from pancreatic fluid, pancreatic cyst fluid and combinations thereof.
 12. The method of claim 1, wherein a corrected carcinoembryonic antigen level above a predetermined carcinoembryonic antigen threshold is indicative of a pathological condition.
 13. The method of claim 12, wherein the carcinoembryonic antigen level threshold is about 192 ng/ml or about 400 ng/ml.
 14. The method of claim 12, wherein the pathological condition is a neoplastic condition or a non-neoplastic condition.
 15. The method of claim 14, wherein the neoplastic condition is selected from colorectal carcinoma, gastric carcinoma, cholangiocarcinoma, pancreatic carcinoma, intraductal papillary mucinous neoplasm (IPMN), lung carcinoma, breast carcinoma, medullary thyroid carcinoma, and combinations thereof.
 16. The method of claim 14, wherein the non-neoplastic condition is selected from ulcerative colitis, pancreatitis, pancreatic cysts, pancreatic masses, biliary strictures, cirrhosis, chronic obstructive pulmonary disease, Crohn's disease, intraductal papillary mucinous neoplasm (IPMN), and combinations thereof.
 17. The method of claim 1, wherein the carcinoembryonic antigen level is multiplied by a correction factor to obtain a corrected carcinoembryonic antigen level when the amylase level in the diluted sample is above about 20,000 units. 